Core Clerkship Asessment - PACS Guidelines

These exercises will begin to give you a familiarity with the workflow in radiology and give you a chance to try out a work station that simulates the functionality of what radiologists use on a daily basis. Keep in mind that the principal goal is not to make you a radiologist, but rather to teach the discipline of radiologic analysis: placing the imaging findings in the context of the clinical problem. The exercise of formulating your thoughts into a concise radiology report helps you to learn how to describe the findings you see on the image, putting our analysis of them together as an impression, and then communicating these clearly to a clinician (whom you may never see face to face).

Cases will be emailed to you prior to the review sessions. Please complete the reports as a word document, print or bring a copy for the session, and send copies to Scot, Dr. Karimova or Dr. Sun via email the day before the review sessions.

  Visage Reference

Components of a Radiology Report - Who, how, when, why, what

  1. Who: identify patient name, number, date of exam, type of exam.
  2. How: identify technique of exam (ie projections used, contrast given, slice thickness, scan interval, etc).
  3. When: Comparison exams with dates (if available).
  4. Why: give clinical indication for the exam (a symptom or sign).
  5. What: describe pertinent positive and negative findings.
  6. Impression: give the overall impression of what the exam shows. This should be in the form of a likely diagnosis or differential diagnosis, and it should relate to the clinical indication given for the exam. It may also include recommendations for follow‐up.

Tips:

  1. Use complete sentences and avoid abbreviations whenever possible.
  2. Try to separate the findings you make from the impression you give; the findings should be simply stated using proper radiologic terminology, while the impression should be a synthesis of the findings (and not merely a restatement of the findings!)
  3. Keep the observations brief and to the point; brevity is a virtue!

Sample Reports

PATIENT: XX

INDICATION: 59-year-old female with chronic right lower quadrant pain for one year.

TECHNIQUE: CT scan of the abdomen and pelvis was performed with intravenous injection of 100 mL Omnipaque 350 and with Omnipaque 240 enteric contrast material.

COMPARISON: CT abdomen and pelvis performed June 17, 2015.

FINDINGS:

LOWER CHEST: Stable 0.4 cm left lower lobe pulmonary nodule (2:6). Unchanged 0.3 cm nodule in the left lower lobe (2:9). No new pulmonary nodules. Heart is normal in size.

LIVER: No focal lesions.

BILIARY SYSTEM: Multiple gallstones are seen, without gallbladder wall thickening or pericholecystic inflammation. No biliary dilatation.

PANCREAS: Normal.

SPLEEN: Normal.

ADRENAL GLANDS: Normal.

KIDNEYS: Normal.

BOWEL: Small hiatus hernia. No bowel thickening or dilatation. Large amount of fecal matter in the large bowel loops suggesting constipation.

MESENTERY, OMENTUM AND PERITONEUM: No mass or ascites.

RETROPERITONEUM: No mass or hemorrhage.

PELVIC ORGANS: Prior hysterectomy. Normal adnexa. Bladder appears normal. Few calcified phleboliths are seen in the deep pelvis.

LYMPH NODES: No enlarged lymph nodes. Prominent inguinal lymph nodes are likely reactive.

VASCULATURE: Opacified abdominal and intrahepatic vasculature is patent.

BONES AND SOFT TISSUES: No destructive osseous lesions. Mild degenerative changes in the spine.

IMPRESSION:

  1. Cholelithiasis without evidence of cholecystitis.
  2. Large amount of fecal matter in the large bowel loops suggesting constipation which could be cause of abdominal pain.
  3. Small hiatal hernia.
  4. Unchanged tiny left lower lobe pulmonary nodules, likely inflammatory given stability over 2 years.

PATIENT: XX

INDICATION: 21-year-old postpartum day 12. Transferred from outside hospital. Status post vaginal delivery. Additional clinical history is obtained from Dr. Hariton's progress note from 8/29/2017. Underwent laparoscopy and laparotomy for post-partum abdominal pain with concern for ovarian torsion without identification of adnexal mass. Post-operative persistent fevers concerning for retained products of conception and endometritis with attempted D\T\C however vaginal wall mass seen on D\T\C. Subsequent CT revealed left vaginal wall hematoma.

TECHNIQUE: CT scan of the abdomen and pelvis was performed with intravenous injection of 75 mL Omnipaque 350 and with Omnipaque 240 enteric contrast material.

COMPARISON: No historical exams for comparison.

FINDINGS:

LOWER CHEST: Respiratory motion artifact. Small wedge-shaped area of opacification within the right lung base, likely peripheral mucous plugging. Heterogeneous appearance of bilateral breasts, likely secondary to lactation. No pulmonary nodules. Heart size is normal. No pleural or pericardial effusion.

LIVER: Normal size and attenuation. No focal lesions.

BILIARY SYSTEM: Layering sludge within the gallbladder. No ductal dilatation. No gallstones.

PANCREAS: Normal parenchyma. No masses or ductal dilatation.

SPLEEN: Normal size and attenuation.

ADRENAL GLANDS: Normal.

KIDNEYS: There is a single hyperattenuating focus within the lower collecting system of the left kidney measuring 4.5 mm, renal calculus. No hydronephrosis on either side. No mass.

BOWEL: No bowel thickening or dilatation.

MESENTERY, OMENTUM AND PERITONEUM: There is minimal air within the peritoneal cavity. Moderate amount of air within the abdomen however majority is extraperitoneal. Small umbilical hernia and diastasis recti. No masses or ascites.

RETROPERITONEUM: No mass or hematoma.

PELVIC ORGANS: There is a large heterogeneous appearing collection along the left vaginal wall, measuring 9.6 x 6.6 cm (image 2:78). There is layering dense material within this collection. The uterus is enlarged, consistent with postpartum state. There is gas and hyperattenuating material within the endometrial cavity, likely related to post-partum state.

There is some air within the bladder in addition to a Foley catheter.

LYMPH NODES: No lymphadenopathy.

VASCULATURE: Normal sized aorta. Patent intra-abdominal and intrahepatic vasculature.

BONES AND SOFT TISSUES: There is gas within the soft tissues of the anterior abdominal wall. No lytic or blastic lesions. No soft tissue masses or edema.

IMPRESSION:

  1. Large left vaginal wall hematoma. Small amount of free fluid within the pelvis.
  2. Gas within the endometrial cavity could related to endometritis versus recent instrumentation.
  3. Subcutaneous gas and pneumoperitoneum, likely related to recent laparotomy.
  4. Left nephrolithiasis without hydronephrosis.

PATIENT: XX

INDICATION: SSX: Chest pain.

COMPARISON: Chest radiograph dated 7/27/2016.

TECHNIQUE: PA and lateral views of the chest.

FINDINGS:
The lungs are clear. There is hyperinflation of lungs. No focal mass, consolidation, pleural effusion, or pneumothorax is seen. The cardiomediastinal silhouette is notable for a moderate sized hiatal hernia. Mild multilevel degenerative changes are seen in the thoracic spine.

IMPRESSION:

  1. No acute abnormality.
  2. Moderate-sized hiatal hernia, unchanged from the prior chest radiograph.

PATIENT: XX

INDICATION: fall on bicycle, pain right posterior ribs, chest wall pain

TECHNIQUE: PA and lateral views of the chest, 6/3/2017. Two views of the right ribs.

COMPARISON: Chest radiograph 4/17/2015.

FINDINGS:
There is no focal consolidation, pulmonary edema, or pleural effusion. There is an apical pneumothorax measuring approximately 15 mm from the pleural surface. The cardiomediastinal silhouette is unremarkable. There are mildly displaced fractures of the lateral right fifth through 7th ribs.

IMPRESSION:

  1. There is a small apical pneumothorax.
  2. There are mildly displaced fractures of the lateral right fifth through 7th ribs.

PATIENT: XX

INDICATION: fever and shortness of breath

TECHNIQUE: PA and lateral views of the chest, 6/3/2017.

COMPARISON: Chest radiograph 4/17/2015.

FINDINGS:
Cardiomediastinal silhouette is normal. There is a right lower lobe opacity with an air bronchogram.; the remaining lung fields are clear. There are no effusions. The bony thorax appears normal. The right lower lobe opacity is new since the comparison exam.

IMPRESSION:
Probable right lower lobe pneumonia